title: Missed opportunities: use of an end-of-life symptom management order protocol among inpatients dying expected deaths.
abstract: BACKGROUND
  When a patient is expected to die, the ideal plan of care focuses on comfort. Prior investigation of application of one institution's end-of-life symptom management order (ESMO) protocol suggested that comfort measures were often instituted too late and sometimes not at all. We studied patient factors associated with missed opportunities for use of an ESMO protocol and protocol adherence in order to identify areas for quality improvement.
  
  
  METHODS
  We abstracted the terminal hospitalization medical record for all adult decedents hospitalized for at least 3 days between April 2005 and April 2006 (n = 496) at a university medical center. Detailed information was collected about ESMO use and opiate titration at the end of life. Among patients expected to die, we used multivariate logistic regression to evaluate factors associated with whether patients were placed on the ESMO protocol prior to death.
  
  
  RESULTS
  Half of patients who died received ESMO protocol care (n = 248). All had documentation of a do-not-resuscitate (DNR) order (a requirement of the protocol). An opiate drip was used for 95% of patients placed on the ESMO protocol and it was titrated up at least once for 67% of those patients. Patients had a mean of 4 opiate titrations, but for only a mean of 2.2 was a justification documented (symptom documentation is required for each titration per the protocol). In a multivariable regression accounting for other demographic, clinical and provider variables, uninsured patients (risk ratio [RR] 0.25, 95% confidence interval [CI] 0.06-0.62), patients admitted from a nursing home (RR 0.57, 95% CI 0.30-0.99), and patients considered for transplant (RR 0.60, 95% CI 0.40-0.85) were significantly less likely to be placed on the ESMO protocol prior to death.
  
  
  CONCLUSIONS
  Evaluation of implementation of a standardized order set can identify areas for quality improvement and missed opportunities for use.
authors.affiliation: Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, California, USA. awalling@mednet.ucla.edu
authors.forename: Anne M
authors.initials: AM
authors.lastname: Walling
authors.forename: Susan L
authors.initials: SL
authors.lastname: Ettner
authors.forename: Tod
authors.initials: T
authors.lastname: Barry
authors.forename: Myrtle C
authors.initials: MC
authors.lastname: Yamamoto
authors.forename: Neil S
authors.initials: NS
authors.lastname: Wenger
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D007297:Inpatients; D016015:Logistic Models; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D010166:Palliative Care / Q000706:statistics & numerical data*; D010347:Patient Care Planning; D019452:Terminally Ill; D055815:Young Adult